Provider Demographics
NPI:1316784424
Name:MARTIN, REILLY ANNE
Entity type:Individual
Prefix:
First Name:REILLY
Middle Name:ANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 HARVEST MOON TRL
Mailing Address - Street 2:
Mailing Address - City:CAPRON
Mailing Address - State:IL
Mailing Address - Zip Code:61012-9302
Mailing Address - Country:US
Mailing Address - Phone:815-451-1108
Mailing Address - Fax:
Practice Address - Street 1:1095 PINGREE RD STE 209
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-1727
Practice Address - Country:US
Practice Address - Phone:847-458-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242007331235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist